The World Health Organisation (WHO) views obesity as the most serious public health problem of the 21st century and has labelled it as the leading preventable cause of death worldwide. Obesity is a disease in which excess body fat has accumulated to the extent that it is having a negative effect on health, which if untreated leads to significant morbidity and reduction in life expectancy. The problem has hit epidemic proportions in India as morbid obesity is affecting 5% of the population, which is surprising in a country where over 250 million people live below the poverty line.
In western countries a Body Mass Index (BMI), which is the ratio of the individualās weight divided by the body surface area in metre2 more than 25 kg/M2 is considered overweight. Due to a genetic tendency of Indians towards abdominal obesity and an increased risk of lifestyle diseases like diabetes, high blood pressure, obstructive sleep apnoea, infertility, arthritis and depression, the Ministry of Health & Family Welfare along with the Indian Council of Medical Research (ICMR) updated its guidelines in 2012 and considers Indians with a BMI over 23 kg/M2 as overweight; BMI over 25 is considered obese and more than 32.5 an indication for Bariatric surgery, in those with a co-morbidity such as Diabetes or high blood pressure, and in all who have a BMI more than 35.
What causes Obesity?
Energy Imbalance: An individual gains weight when he / she consumes more calories than the body can use through its normal functions (basal metabolic rate or BMR) and physical activity. The unused calories are then stored as fat and the person becomes obese if he / she consistently consumes excess calories over a length of time.
Genetic or Hereditary Factors: A very few patients inherit the tendency to gain weight. Genes may play an important role in tendency to gain excess weight. Just as some genes determine eye color or height, others affect our appetite, our ability to feel full , our metabolism, our fat-storing ability, and even our natural activity levels.
Environmental Factors: Environmental and genetic factors are obviously closely intertwined. Modern lifestyle and environment such as fast foods which are high in fat and low in fruits and vegetables, sedentary work and lack of regular excercise all magnify hereditary factors such as metabolism and efficient fat storage. For those suffering from morbid obesity, anything less than a total change in environment usually results in failure to reach and maintain a healthy body weight by non-operative measures.
Common complications of obesity
Heart disease: Severely obese persons are approximately 6 times as likely to develop heart disease as compared to those with a normal weight. Heart disease is the leading cause of death today and obese persons tend to develop it earlier in life which shortens their lives.
High Blood Pressure (Hypertension) is much more common in obese persons and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes and kidney damage.
Diabetes Mellitus: Overweight persons are 40 times as likely to develop type-2, (adult onset) diabetes. Once diabetes occurs, it becomes even harder to lose weight because of hormonal changes which cause the body to store fat even more than before.
Deranged lipid profile adds to the damage to blood vessels caused by diabetes and high blood pressure ads to the incidence of heart disease and brain stroke.
Obstructive Sleep Apnea (OSA): Apnea, which means repeated failure of breathing during sleep, is common in the obese because of compression of the air passage by fat which gives rise to headaches, feeling of dullness, repeatedly dozing off during the day, high blood pressure and respiratory insufficiency.
Gastro esophageal reflux disease (GERD) and nocturnal reflux aspiration of stomach contents into the throat cause heartburn due and recurrent bronchitis and bronchial asthma.
Non-alcoholic steato-hepatitis (NASH) due to fatty infiltration of the liver is a precursor of liver failure.
Obese people are 40 times more likely to develop type-2 diabetes. Once it occurs, it gets even harder to lose weight
Gallstone Disease occurs several times frequently in the obese, in part due to repeated efforts at dieting, which predispose to this problem.
Sub ā fertility due to polycystic ovarian disease (PCOD) and low sperm count are commonly seen in the morbidly obese.
Degenerative disease of lumbo-sacral spine (backbone) leads to persistent back ache and sciatica.
Degenerative arthritis of weight bearing joints like knee and hip occur in the early age, leading to inability to exercise and thus starts a vicious downward spiral of progressive weight gain.
Venous stasis in the lower extremities leads to deep vein thrombosis, swelling and discoloration of the ankles and feet
Emotional / psychological illness: Seriously overweight persons face constant challenges to their emotions due to repeated failure with dieting, disapproval from family and friends and remarks from strangers.
They often experience discrimination at work ; they are assumed to be lazy which results in low self ā esteem and poor body image.
Anxiety and depression might accompany years of suffering from the effects of a genetic condition, which skinny people believe could be controlled easily by will power.
Bariatric (weight-loss) Surgery
Bariatric surgery alters the digestive system to help people lose weight at an average rate of one to three Kg per week (depending upon the procedure performed) thus significantly reducing all the related health issues. This weight loss is achieved by reducing the size of the stomach by removal of a portion of the stomach (sleeve gastrectomy or bilio-pancreatic diversion with duodenal switch) or by re-routing the small intestines to a small stomach pouch (gastric bypass surgery).This surgery is very different from liposuction, as no fat is removed during the operation. The fat is lost by the patient by adhering to a diet and undertaking regular exercise. The alteration made in the digestive tract makes it easier for the individual to follow the dietary advice, as appetite is reduced and a small amount of food gives the patient a sensation of satiety and fullness, besides which, after a bypass surgery even if the individual defaults on his prescribed diets a significant amount of nutrients are not absorbed preventing weight regain. Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes and high blood pressure, alleviation of obstructive sleepĀ apnoea, reduction in cardiovascular risk factors and a very significant overall reduction in morbidity and mortality.
Who should get the surgery done?
Limited success has been achieved with a variety of non-surgical approaches including medically supervised dieting. Dieting alone cannot be considered a reasonable option for permanent weight loss. Drug therapy for clinically severe obesity has been disappointing.
It is recommended to seriously consider the surgical option for reducing weight to avoid its ill effects if :-
Your BMI is over 35
Your BMI is 32.5 or higher and you have a serious medical problem (hypertension, diabetes, heart disease, joint problems, reflux) that is made worse by obesity
You have been unable to reduce weight or maintain weight under medically supervised programĀ
You have been obese for 5 years
However, you should not have a history of alcohol abuse or suffer from depression or other major psychological / emotional disorder
Bariatric surgery is only a tool to help patients follow a diet plan and achieve weight-loss faster and for a prolonged duration
Laparoscopic gastric sleeve resection which is purely a restrictive procedure is a very popular operation in which the size of the stomach is reduced from a bag to a tube leaving a small pouch near its lower end, `where only about 50 ml of food or drink can be held. There is no change in the way that food passes through the intestine. However it is not reversible as the resected portion of the stomach is removed from the body.
The other commonly done procedure is the Gastric Bypass (Roux-en-Y / Mini) where a small pouch or tube is separated from the stomach and anastomosed to the small intestine after bypassing a certain variable length of bowel. It is thus a restrictive cum malabsorbtive procedure. The advantage in this procedure is that the weight loss is faster and more sustained and it is theoretically reversible, however a closer watch needs to be kept on dietary supplements because of the malabsorbtive element lest the patient develop serious deficiencies of proteins, vitamins and minerals.
Minimal access surgery
The operations are done by laparoscopic technique, in which 5 small incisions are given and specially designed ports used to insert a telescope behind which a camera is attached. The camera sends the real time image to a high resolution monitor. Using this magnified vision the surgery is done using specialized delicate instruments and staplers. Thus the post-operative discomfort is minimized and recovery is much faster. The patient is ambulant by the evening of surgery and can start oral fluids after 48 hours, go home in three to four days, resume work in 10 days and consume normal home cooked food in 3 ā 4 weeks.
Suggested Lifestyle Changes
For long-term weight loss and health improvement following surgery, you must initiate some lifestyle changes right away and start living as if youāve had the surgery already:
Begin eating for health and not for taste and satiety
Stop drinking alcohol
Stop sugared beverages and drink more water
Eat slow, chew each bite and watch the portion sizes
Eat lots of protein (egg white, steamed fish and chicken, high protein additives)
Eat lots of fruits, salads, sprouted dal and vegetables so as to feel full
Donāt drink anything with your meals
Avoid coffee & stop smoking
Some myths of Bariatric Surgery
Myth: Youāll live on a liquid diet and protein shakes for the rest of your life & it will be difficult to eat with family and friends.
Truth: All patients put on a liquid diet for 10 ā 14 days before and after surgery, to help with the operation and healing process. A couple of weeks post-surgery, they are weaned off liquid diet and soon all patients eat small quantities of home cooked food. Dieticians work with patients to show them the kinds of meals they can make that will fit in their new healthy lifestyle, which can actually be shared with family members and friends.
Myth: Bariatric surgery is the easy way out.
Truth: Bariatric surgery is only a tool to help patients follow a diet plan and achieve weight-loss faster and for a prolonged duration, and to prevent a rebound weight gain by cutting their appetite and inducing early satiety. If patients donāt follow a healthy diet, exercise, and take their vitamins, it wonāt work.
It is possible to have children after weight loss surgery. In fact the fertility level increases in most of the cases
Myth: You will be left with a big scar after weight loss surgery.
Truth: All weight loss surgeries are now carried out laparoscopically. You will be left with a very small mark. The laparoscopic technique allows a surgeon to perform complex procedures that used to require the conventional large incisions through minimal access.
Myth: You cannot get pregnant after weight loss surgery
Truth: It is possible to have children after weight loss surgery, your fertility will improve. However, most doctors will advise you to wait for 1-2 years . This is because you need to wait until your weight loss has stabilized.
Dr (Maj Gen) Atul K Sharma, AVSM, is Sr Consultant G I, Laparoscopic & Bariatric Surgery and Chairman Institute of Gastrointestinal Sciences at Alchemist Hospitals, Panchkula